Pilot faulted for Mauna Loa crash that killed 10

By Walter Wright
Advertiser Staff Writer

The National Transportation Safety Board has blamed the pilot for the Sept. 25, 1999, crash of a tour plane on Mauna Loa in which all 10 aboard were killed.

In findings adopted Wednesday, the board said pilot Dennis O'Leary decided to fly without instruments near the cloud-shrouded mountain on the Big Island.

"The National Transportation Safety Board determines that the probable cause of this accident is the pilot's decision to continue visual flight into instrument meteorological conditions (IMC) in an area of cloud-covered mountainous terrain," the board said.

The Big Island Air Piper Chieftain piloted by O'Leary was equipped with instruments, and global positioning satellite receivers, "which could have been used to indicate the accident airplane's position and ground clearance" the NTSB report said.

Although the pilot was not required to use these navigational aids, he should have used them to accurately monitor his ground track and altitude, the board said.

"During the last few minutes of flight, when the airplane's ground clearance was rapidly decreasing, the pilot did not reverse course or take emergency action," the report said.

"Radar data indicates that at this point in flight, the airplane's track varied little from its predominately west-northwesterly direction.

"If the pilot had been using his navigational aids correctly, he would have realized that he was nearing high terrain and would likely have changed his course."

In addition to O'Leary, nine sightseers — four men and five women — were killed.

O'Leary had engaged in similar risky flying only a few weeks before the fatal accident, the NTSB said.

On September 27, 1999, two days after the accident, the Safety Board received correspondence from a passenger who had flown with the O'Leary during a Big Island Air sightseeing tour on September 4, 1999. "The passenger's description of the flight route was similar to that of the accident flight," the report said.

"The passenger indicated that during his tour, the pilot had flown in dense clouds that prevented him from being able to see both ahead of and below the airplane."

And there was proof: Investigators subsequently viewed photographs taken by the passenger and a videotape made by the passenger during his flight. "The tape showed the airplane flying in clouds on several occasions and in different locations throughout the flight."

Several sources indicated cloudy conditions on the mountain at the time and location of the crash, the report said.

The fatal flight normally would have followed a course around the island, first to Upolu Point, then toward Hilo, then toward the Pu'u O'o vent and then to the summit of Kilauea. Return would normally have been by flying around South Point and along the western shoreline of the island back to Keahole-Kona.

But the company told NTSB that its pilots frequently fly back from the Hilo area via the "saddle route" between the two mountains — but only if that were possible without encountering weather requiring instruments.

Flying into instrument-condition weather was a violation of Big Island Air's company policy for pilots to reverse course if they encountered such conditions, the report said.

A Big Island Air official, contacted yesterday, said she had not yet seen the report and that the company had no immediate comment.

Other factors contributing to the accident, the NTSB said, "were the pilot's failure to properly navigate and his disregard for standard operating procedures, including flying into IMC while on a visual flight rules flight plan and failure to obtain a current preflight weather briefing."

O'Leary, who had logged more than 11,500 hours of flight time with several Hawai'i air tour operators, had lived for several years on Maui and was a resident of Hawai'i Kai at the time of the accident.

NTSB investigators interviewed O'Leary's landlord on O'ahu, and were told that the night before the crash, the pilot went to bed about 9 p.m.

"The landlord also indicated that because the pilot had an early morning flight on September 25, he would likely have arisen about 4 a.m. and then driven to the Honolulu International Airport and flown on a commercial flight to the Keahole-Kona Airport to begin work.

"The pilot's early awakening time and the length of his duty day raise the possibility of fatigue as a factor in this accident. However, in the absence of further evidence, the Safety Board cannot conclusively determine whether fatigue was a factor in this accident," the report said.

Toxicology tests revealed an amount of phentermine, a prescription stimulant and diet aid in the same drug class as amphetamine, in the pilot's liver.

Phentermine has potential side effects including insomnia, irritability, hyperactivity, personality changes and extreme fatigue and depression following acute withdrawal, the agency said.

But "because no blood sample from the pilot was available for analysis, the impact of the drug phentermine on pilot's behavior could not be analyzed or determined," the report said.

Analysis indicated that during the last half minute of flight, before the airplane slammed into Mauna Loa at an elevation of 10,100 feet, it was probably flying at its maximum rate of climb as the pilot attempted to gain greater altitude.

Reach Walter Wright at wwright@honoluluadvertiser.com or 525-8054.